cardiac electrophysiologist, cyclist, learner

Do doctors know how to treat high blood pressure and high cholesterol?

Blood pressure and cholesterol problems affect millions. These are the bread, butter and sugary drinks of Internal Medicine and general Cardiology practice.

It stands to reason then, that the treatment of these basic maladies would be well agreed upon. Guidelines and expert consensus statements would be clear and up-to-date.

But this is far from reality.

This recent story on theHeart.org chronicled the fact that treatment guidelines for high blood pressure and high cholesterol are a decade old. (And the last word on best practice for obesity treatment was 15 years ago.)

Surely this death of clarity is worthy of comment. A baker can bake bread and a mechanic can change the oil. A medical doctor should know how to treat high blood pressure and high cholesterol.

But the fact remains that we have no contemporary guidelines. Let me repeat: There is no expert consensus on how to treat blood pressure and cholesterol issues. Wow.

It’s worth thinking about why and how this came to be. Perhaps recent disruptions in dogmatic medical thinking have played a role?

Consider these facts:

We’ve learned that treating to biomarkers (surrogate endpoints) isn’t such a good idea. Witness niacin and HDL.

We’ve also learned that strict control of blood pressure may worsen outcomes in diabetics and the elderly.

Another shocker is that the common practice of titration to certain cholesterol levels has a dubious evidence base.

The role of exercise has only complicated matters. It’s now clear that real exercise (that which makes one fit) is an effective and safe therapy. How does one work this pearl into the guidelines? How much adherence should a doctor expect before unleashing the pills-with-side-effects strategy?

And nutrition: Will the guidelines say something about the fact that doctors can’t stop patients from making bad food choices? Yes, we can click a box that says we discussed nutrition, but that doesn’t make people eat well. And we don’t all live in NY city.

The role of sleep. Ten years ago sleep disorders were not on the radar. Now, with the explosion of societal inflammation and obesity-thickened necks, sleep apnea has roared to epidemic-like prevalence. You can’t be healthy without good sleep.

Yet none of these disruptions were cited as reasons for the delay. Rather, one of the co-chairs of the writing committee (a government agency) said the delay was due to lack of resources. The writing committee had to use video-conferencing rather than fly people in for a couple of days of meetings. That’s funny.

I believe—at least I want to believe—experts are struggling with the less-is-more philosophy. Steve Stiles’ coverage on theHeart.org highlighted the problem of incorporating healthy lifestyles into the guidelines. How thought leaders handle this elephant in the room interests me immensely. Will they be strong and say that many (most) patients could avoid exposure to therapeutic harm if they made basic healthy lifestyle choices? Or will the un-inspiring vanilla language remain: “when lifestyle changes aren’t effective, start with drug X, Y or Z?” Gosh, it would be disappointing if medical leaders fail to place the primary therapy of high blood pressure, high cholesterol and obesity on the patient rather than the doctor.

Don’t misunderstand; there is a role for medical therapy here, especially in the secondary prevention of heart disease and stroke. I simply hope for a major change in philosophy—away from pills and towards lifestyle choices.

Before concluding with dreamy optimism, there are two other possible factors in the delay of consensus statements:

The media situation is different now. Within seconds of hitting the publish button these documents will spread through social and mainstream media for analysis and commentary. Think amplify. Gone are the days when documents languished in medical journals. The writers must know this, and it must be a little scary.

I also wonder if guideline writers are considering the power they wield. Guidelines are no longer used only for guidance. Now, the noun ‘guideline’ has morphed into ‘rule.’ Guidelines quickly become boxes to click on EMR programs, quality measures, and soon, the number of patients a doctor has on certain drugs will become a means of compensation. Oh, what a bad idea that is.

Now for magical thinking:

Perhaps the guideline writers will throw up their hands and admit the truth: the treatment of high blood pressure, high cholesterol and obesity have grown so complicated and dependent on individual responsibility that we couldn’t possibly offer any useful standard protocols? We offer no guidelines!

They will say that each patient must be assessed and therapy be individually directed and aligned with patient-centered goals. And that medicine is overused and lifestyle choices are underused.

Comments

Nice article.
There really should be no “thought leaders”.
Guidelines should be individualized, not standardized.
What we have today is the govt-corporate-insurance-industrialized medical complex.
What docs need to realize is that corporations can not care for individuals.

Maybe you need a protocol, a template, a checklist, a guideline, and a recommendation on how to encourage people to take charge of their own health. All the focus on health care cost puts the burden on the doctor. We need more health and less care.

Not an exhaustive list but I’ve used a fairly close variation of this list with my patients for years, treating the cause (Nutrition/lifestyle) and not symptoms (Obesity, High blood pressure, etc.) with excellent results.

Dr. Mandrola is hitting on a truism in medicine. We’re doing and spending too much trying to overcome poor lifestyle choices by our patients.

For the average patient (me for example) the information and guidance can be often quite contradictory and confusing. It seems that almost daily one study comes out that is totally out of phase from a study released several weeks ago.

The common sense approach you always preach makes the most sense. Human nature being what it is though (we are all human, after all – at least most of us), we wander in and out of common sense throughout our lives. Genetically, some of us have body systems that can cope with that. Others seem to have health problems at the drop of a hat, regardless of diet and exercise.

Piggybacking on your last blog, maybe part of the problem is too many ‘ologists’, and not enough common sense GPs. This is not a reflection on you or other ‘ologists’ who are needed, but far too often, for whatever reason, a GP these days, seems to be mostly a clearing house for specialists and drugs, probably given the constraints of not being able to spend enough time with a patient to actually hear what they say, and getting to know them as a patient, and offering common sense advice. It’s mostly, say hi, what’s your complaint, here’s a pill, and I’ll refer you to . . .

I’m fortunate to not have a GP like that, but I’ve run into many of them, as well as ‘ologists’ who send folks to other ‘ologists’ and each ‘ologist’ has a contradictory set of guidelines and protocals from the other ‘ologist’ that don’t mix. (he didn’t put you on THAT medication, did he? – bedrest is best,no, get up and move, eat this, no eat this and DON’T eat that.)

Your point in an excellent post a while back hits home as well to me regarding ‘physician heal thyself’. I vividly remember a doctor I had growing up, who would sit behind his desk, smoking a cigarette (shows my age, huh) lecturing us kids about the dangers of bad health habits. Incredible! He died of a massive MI on a weekend of (rumour had it, and later pretty much confirmed) of binge drinking. Proved he was all too human, despite the guidelines of the day. I know physicians are human too, despite all of the guidelines they have access to, but it’s hard to get a lecture about diet and exercise, from someone 50 pounds heavier than you.

Face it, we are all impossible . . . . . . . . . . besides, life today is a constant barrage of tensions and inflammations – the basics of afib and heart disease.

Thanks for the thoughtful words. Great comment. Keep them coming. We are all just ambling through life trying to the best we can, while being flawed to the gills. Humans are something. Beautiful blog material, we are.

Also, let me clarify one of my comments. Regarding GPs and ‘ologists’, my GP seems to do a great job as an ‘ologist’ co-ordinator, rather than just as a clearinghouse. He talks with them about his, and their, mutual patients – on the patients behalf, and seems to do a great job filtering out the noise, managing the different opinions, and translating the terminology into English we can understand.

He also does the most important thing of all – he LISTENS. He doesn’t just treat me for what I came in for at the moment, he manages to make time to understand my life, ask me about my daughter, my job, about stressors – that kind of stuff. And somehow he manages to do this with all of his patients. I know every doctor has a different personality, and some of the best doctors have zero bedside manner (and I certainly would want them treating me, if I should need their services), but for the day-to-day GP, that skill of listening is a gift that is vastly underappreciated today. Sometimes just having someone listen to you, without judgement, is the best cure you can find.

Keep up the great blogs. They are so informative and, yes, entertaining.

John – I agree completely with your Comments in this excellent post. Among the most under appreciated concepts are NNT (as well as NNH = number needed to treat or harm) – as well as benefit/harm ratios for incremental risk factor reduction.

For example – strict adherers to published BP Guidelines (who as you say, often do little more than lip service for advising patients about lifestyle change) – tend to routinely reach for higher doses and additional drugs until BP is lowered to specified target number (say under 140/85) – whereas in reality, biggest “bang for buck” occurs with the initial incremental reduction (say from a BP of 180/100 down to 160/90) – with proportionally smaller benefits from additional BP reduction (down to 150/90). Yet side effects tend to do the opposite (increase the higher the dose and the more drugs that are used). Therefore – there comes a point of diminishing benefit (and increased potential for harm) – with this point often arising before the specified “target number” BP is reached … Rather than strict adherence to number targets – individualizing decision of how much BP reduction is optimal for each patient (vs potential for adverse effects) should be the goal.

Then there is the question of how many patients would want to pay the cost and risk the chance of developing adverse effects if they knew (ie, for use of statins in primary prevention) that 49 patients would need to take the drug for 5 years in order for 1 patient to benefit (with NO benefit at all being accrued by the other 49 patients). And yet detailed Guidelines for how primary prevention should be done are widely put forth …

Even more perplexing, recent research suggesting statin drugs increase risk of diabetes and even coronary calcifications. I believe the population of patients with ANY benefit from statins could be far more narrow than we currently realize.

I’m in complete agreement with your comments on bp control and modifying goals individually to attain a balance between max risk reduction and side effect.

In my practice, I like to focus on patient responsibility and education on effective lifestyle choices to “Cure” their own ailments. I’m encouraged by how many patients hear that message when it’s articulated during an office visit.

THANKS William for your Comment. It is a shame so much of what is done is “about the money” (ie, it is of obvious interest to pharmaceutical companies making statins for this medication to be in the drinking water). I do believe that statins HAVE an important role for secondary prevention – but the issue of “money” unfortunately clouds assessment as to who really benefits from primary prevention (my opinion) – with concept of NNT (and NNH) showing how primary prevention for all is anything but a foregone conclusion …

This is an off topic request, but I just figured out that I can leave a comment. Have you written any posts about a “pill in the pocket” approach for those of us older athletes with occasional a-fib episodes, once every two to three months?
Thank you and am very happy to have found your site.

My wife used to (jokingly of course) threaten to purchase one of those automated defibrillator devices that are now often found in public spaces (arenas, gyms, sports fields etc) and use it on me at home. She figured that it would save a trip to the hospital for yet another electrocardioversion.

John Mandrola, MD

Welcome, Enjoy, Interact.
I am a cardiac electrophysiologist practicing in Louisville KY. I am also a husband to a palliative care doctor, a father, a bike racer, and a regular columnist at theHeart.org | Medscape